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FfSojo — ooio • FUNDAMENTALS AI" 72-41 FIRE ALARM AND EMERGENCY COMMUNICATION SYSTEM RECORD OF COMPLETION To be completed by the system installation contractor at the time of system acceptance and approval. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Attach additional sheets,data, or calculations as necessary to provide a complete record. 1. PROPERTY INFORMATION Name of property: Pediatric Associates NW Ad ress: �eV SW Dartmouth St.Tigard,OR 97223 Description of property: Medical Clinic Occupancy type: Group B Name of property representative: Address: Phone: Fax: E-mail: Authority having jurisdiction over this property: Phone: Fax: E-mail: 2. INSTALLATION,SERVICE,AND TESTING CONTRACTOR INFORMATION Installation contractor for this equipment: Cherry City Electric Address: 1596 22nd St.SE,Salem,OR 97302 License or certification number: Phone: Fax: E-mail: Service organization for this equipment: Convergint Technologies LLC Address: 7678 SW Mohawk St,Bldg K Tualatin,OR 97062 License or certification number: 148358 Phone: 503-228-8522 Fax: 503-228-8521 E-mail: A contract for test and inspection in accordance with NFPA standards is in effect as of: Contracted testing company: Address: Phone: Fax: E-mail: Contract expires: Contract number: Frequency of routine inspections: 3. DESCRIPTION OF SYSTEM OR SERVICE 0 Fire alarm system(nonvoice) ❑ Fire alarm with in-building fire emergency voice alarm communication system(EVACS) ❑ Mass notification system(MNS) ❑ Combination system,with the following components: ❑ Fire alarm ❑ EVACS ❑ MNS ❑Two-way,in-building,emergency communication system ❑Other(specify): ©2009 National Fire Protection Association NFPA 72(p.1 of 12) FIGURE 10.18.2.1.1 Record of Completion. ConygfnI T E C.H' /0 L 0 G S 2010 Edition Making a Daily Difference • 72-42 NATIONAL FIRE AI ARM AND SIGNALING CODE 3. DESCRIPTION OF SYSTEM OR SERVICE (continued) NFPA 72 edition: 2013 Additional description of system(s): 3.1 Control Unit Manufacturer: Edwards Model number: 10-64 3.2 Mass Notification System 0 This system does not incorporate an MNS. 3.2.1 System Type: ❑In-building MNS—combination ❑In-building MNS—stand-alone .1 Wide-area MNS U Distributed recipient MNS ❑Other(specify): 3.2.2 System Features: ❑Combination fire alarm/MNS DMNS autonomous control unit DWide-area MNS to regional national alerting interface ❑Local operating console(LOC) ❑Distributed recipient MNS(DRMNS) ❑Wide-area MNS to DRMNS interface ❑Wide-area MNS to high-power speaker array(HPSA)interface 0 In-building MNS to wide-area MNS interface ❑Other(specify): 3.3 System Documentation 0 An owner's manual,a copy of the manufacturer's instructions,a written sequence of operation,and a copy of the numbered record drawings are stored on site. Location: Electrical Room 3.4 System Software ❑ This system does not have alterable site-specific software. Operating system(executive)software revision level: 10-CU V3.5 Site-specific software revision date: 11/3/2015 Revision completed by: Convergint • A copy of the site-specific software is stored on site. Location: FACP 3.5 Off-Premises Signal Transmission ❑ This system does not have off-premises transmission. Name of organization receiving alarm signals with phone numbers: Alarm: Action Technology Systems Phone: 503 231-1992 Supervisory: Action Technology Systems Phone: 503 231-1992 Trouble: Action Technology Systems Phone: 503 231-1992 Entity to which alarms are retransmitted: Phone: Method of retransmission: AES Radio Communicator If Chapter 26,specify the means of transmission from the protected premises to the supervising station: If Chapter 27,specify the type of auxiliary alarm system: ❑Local energy OShunt ❑Wired GI Wireless C 2009 National Fire Protection Association NFPA 72(p.2 of 12) FIGURE 10.18.2.1.1 Continued Co 'A ' , p/ft r w F 2010 Edition T E C - e E$ Making a Daily Difference FUNDAMENTALS 72-43 4. CIRCUITS AND PATHWAYS 4.1 Signaling Line Pathways 4.1.1 Pathways Class Designations and Survivability Pathways class: B Survivability level: Quantity: 1 (See NFPA 72,Sections 12.3 and 12.4) 4.1.2 Pathways Utilizing Two or More Media Quantity: Description: 4.1.3 Device Power Pathways No separate power pathways from the signaling line pathway ❑Power pathways are separate but of the same pathway classification as the signaling line pathway ❑Power pathways are separate and different classification from the signaling line pathway 4.1.4 Isolation Modules Quantity: 4.2 Alarm Initiating Device Pathways 4.2.1 Pathways Class Designations and Survivability Pathways class: Survivability level: Quantity: (See NFPA 72,Sections 12.3 and 12.4) 4.2.2 Pathways Utilizing Two or More Media Quantity: Description: 4.2.3 Device Power Pathways O No separate power pathways from the initiating device pathway El Power pathways are separate but of the same pathway classification as the initiating device pathway ❑ Power pathways are separate and different classification from the initiating device pathway 4.3 Non-Voice Audible System Pathways 4.3.1 Pathways Class Designations and Survivability Pathways class: Survivability level: Quantity: (See NFPA 72,Sections 12.3 and 12.4) 4.3.2 Pathways Utilizing Two or More Media Quantity: Description: 4.3.3 Appliance Power Pathways No separate power pathways from the notification appliance pathway Power pathways are separate but of the same pathway classification as the notification appliance pathway El Power pathways are separate and different classification from the notification appliance pathway ®2009 National Fire Protection Association NFPA 72(p.3 of 12) FIGURE 10.18.2.1.1 Continued Co � ', l�• nt T E S 2010 Edition iw.F Making a Daily Difference 72-44 NATIONAI.FIRE ALARM AND SIGNALING CODE 5. ALARM INITIATING DEVICES 5.1 Manual Initiating Devices 5.1.1 Manual Fire Alarm Boxes ❑ This system does not have manual fire alarm boxes. Type and number of devices: Addressable: 1 Conventional: Coded: Transmitter: Other(specify): 5.1.2 Other Alarm Boxes 0 This system does not have other alarm boxes. Description: Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other(specify): 5.2 Automatic Initiating Devices 5.2.1 Smoke Detectors ❑ This system does not have smoke detectors. Type and number of devices: Addressable: 1 Conventional: Other(specify): Type of coverage: ❑Complete area SI Partial area ❑Nonrequired partial area Other(specify): Type of smoke detector sensing technology: ❑Ionization 0 Photoelectric ❑Multicriteria ❑Aspirating ❑Beam Other(specify): 5.2.2 Duct Smoke Detectors p This system does not have alarm-causing duct smoke detectors. Type and number of devices: Addressable: Conventional: Other(specify): Type of coverage: Type of smoke detector sensing technology: ❑Ionization Photoelectric ['Aspirating ❑Beam 5.2.3 Radiant Energy(Flame)Detectors 0 This system does not have radiant energy detectors. Type and number of devices: Addressable: Conventional: Other(specify): Type of coverage: 5.2.4 Gas Detectors D This system does not have gas detectors. Type of detector(s): Number of devices: Addressable: Conventional: Type of coverage: 5.2.5 Heat Detectors 9 This system does not have heat detectors. Type and number of devices: Addressable: Conventional: Type of coverage: ['Complete area ['Partial area ❑Nonrequired partial area ❑Linear ❑Spot Type of heat detector sensing technology: ❑Fixed temperature ❑Rate-of-rise ['Rate compensated ©2009 National Fire Protection Association NFPA 72(p.4 of 12) FIGURE 10.18.2.1.1 Continued Co -j ` • raint 2010 Edition T E C - •�L E S il Making a Day Difference FUNDAMENTALS 72-45 5. ALARM INITIATING DEVICES (continued) 5.2.6 Addressable Monitoring Modules ❑This system does not have monitoring modules. Number of devices: 2 5.2.7 Waterflow Alarm Devices ❑This system does not have waterflow alarm devices. Type and number of devices: Addressable: 1 Conventional: Coded: Transmitter: 5.2.8 Alarm Verification Ol This system does not incorporate alarm verification. Number of devices subject to alarm verification: Alarm verification set for seconds 5.2.9 Presignal p This system does not incorporate pre-signal. Number of devices subject to presignal: Describe presignal functions: 5.2.10 Positive Alarm Sequence(PAS) 151 This system does not incorporate PAS. Describe PAS: 5.2.11 Other Initiating Devices O This system does have other initiating devices. Describe: 6. SUPERVISORY SIGNAL–INITIATING DEVICES 6.1 Sprinkler System Supervisory Devices ❑ This system does not have sprinkler supervisory devices. Type and number of devices: Addressable: 1 Conventional: Coded: Transmitter: Other(specify): 6.2 Fire Pump Description and Supervisory Devices Ti This system does not have a fire pump. Type fire pump: ❑Electric Engine Type and number of devices: Addressable:— _ Conventional: Coded: Transmitter: Other(specify): 6.2.1 Fire Pump Functions Supervised ❑Power ❑Running ❑Phase reversal Selector switch not in auto ❑Engine or control panel trouble ❑Low fuel Other(specify): 6.3 Duct Smoke Detectors (DSDs) ❑ This system does not have DSDs causing supervisory signals. Type and number of devices: Addressable: 4 Conventional: Other(specify): Type of coverage: Type of smoke detector sensing technology: ❑Ionization p Photoelectric ['Aspirating ['Beam 6.4 Other Supervisory Devices ❑ This system does not have other supervisory devices. Describe: AES Radio Communicator fault ®2009 National Fire Protection Association NFPA 72(p.5 of 12) FIGURE 10.18.2.1.1 Continued Co f Wilt T E C - S 2010 Edition 0 Making a Daily Difference 72-4(i NATIONAL FIRE ALARM AND SIGNALING CODE 7. MONITORED SYSTEMS 7.1 Engine-Driven Generator O This system does not have a generator. 7.1.1 Generator Functions Supervised ❑ Engine or control panel trouble ❑Generator running ❑Selector switch not in auto ❑Low fuel ❑Other(specify): 7.2 Special Hazard Suppression Systems El This system does not monitor special hazard systems. Description of special hazard system(s): 7.3 Other Monitoring Systems O This system does not monitor other systems. Description of other system(s): 8. ANNUNCIATORS ❑ This system does not have annunciators. 8.1 Location and Description of Annunciators Location 1: Main Lobby-LCD Location 2: Location 3: 9. ALARM NOTIFICATION APPLIANCES 9.1 In-Building Fire Emergency Voice Alarm Communication System 0 This system does not have an EVACS. Number of single voice alarm channels: Number of multiple voice alarm channels: Number of speakers: Number of speaker circuits: Location of amplification and sound-processing equipment: Location of paging microphone stations: Location 1: Location 2: Location 3: 9.2 Nonvoice Notification Appliances ❑ This system does not have nonvoice notification appliances. Horns: 11 With visible: 11 Bells: With visible: Chimes: With visible: Visible only: 8 Other(describe): 9.3 Notification Appliance Power Extender Panels 0 This system does not have power extender panels. Quantity: Locations: ©2009 National Fire Protection Association NFPA 72(p.6 of 12) FIGURE 10.18.2.1.1 Continued Co '- E nt 0 2010 Edition T E C H N ! S S Making a Daily Difference FUNDAMENTALS 72-47 10. MASS NOTIFICATION CONTROLS,APPLIANCES,AND CIRCUITS O This system does not have an MNS. 10.1 MNS Local Operating Consoles Location 1: Location 2: Location 3: 10.2 High-Power Speaker Arrays Number of HPSA speaker initiation zones: Location 1: Location 2: Location 3: 10.3 Mass Notification Devices Combination fire alarm/MNS visible appliances: MNS-only visible appliances: Textual signs: Other(describe): Supervision class: 10.3.1 Special Hazard Notification GI This system does not have special suppression predischarge notification. ❑ MNS systems DO NOT override notification appliances required to provide special suppression predischarge notification. 11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS 11.1 Telephone System El This system does not have a two-way telephone system. Number of telephone jacks installed: Number of warden stations installed: Number of telephone handsets stored on site: Type of telephone system installed: ❑Electrically powered ❑Sound powered 11.2 Two-Way Radio Communications Enhancement System This system does not have a two-way radio communications enhancement system. Percentage of area covered by two-way radio service: Critical areas: % General building areas: Amplification component locations: Inbound signal strength: dBm Outbound signal strength: dBm Donor antenna isolation is dB above the signal booster gain Radio frequencies covered: Radio system monitor panel location: ©2009 National Fire Protection Association NFPA 72(p.7 of 12) FIGURE 10.18.2.1.1 Continued CoflYe/1$In t. T E C.H'N/0 L 0E S 2010 Edition taw a Making a Daily Difference 72-18 NATIONAL FIRE ALARM AND SIGNALING CODE. 11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS (continued) 11.3 Area of Refuge(Area of Rescue Assistance)Emergency Communications Systems xi This system does not have an area of refuge(area of rescue assistance)emergency communications system. Number of stations: Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.4 Elevator Emergency Communications Systems xl This system does not have an elevator emergency communications system. Number of elevators with stations: Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.5 Other Two-Way Communication Systems Describe: 12. CONTROL FUNCTIONS This system activates the following control functions: ❑Hold-open door releasing devices ❑Smoke management 111 HVAC shutdown El F/S dampers ❑Door unlocking ['Elevator recall ['Fuel source shutdown ['Extinguishing agent release ❑Elevator shunt trip ❑Mass notification system override of fire alarm notification appliances Other(specify): 12.1 Addressable Control Modules ❑This system does not have control modules. Number of devices: 4 Other(specify): 13. SYSTEM POWER 13.1 Control Unit 13.1.1 Primary Power Input voltage of control panel: 120VAC Control panel amps: 15 Overcurrent protection: Type: circuit breaker Amps: 15 Location(of primary supply panel board): Electrical room Disconnecting means location: circuit breaker 13.1.2 Engine-Driven Generator o This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: ©2009 National Fire Protection Association NFPA 72(p.8 of 12) FIGURE 10.18.2.1.1 Continued Co ' j77J(nt 0 2010 Edition T E C�7�/ / s e ES Making a Daily Difference FUNDAMENTALS 72-49 13. SYSTEM POWER (continued) 13.1.3 Uninterruptible Power System 0 This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode(hours): In alarm mode(minutes): 13.1.4 Batteries Location: FACP Type: SLA Nominal voltage: 12VDC Amp/hour rating: 10 Calculated capacity of batteries to drive the system: In standby mode(hours):24 In alarm mode(minutes): 5 GI Batteries are marked with date of manufacture p Battery calculations are attached 13.2 In-Building Fire Emergency Voice Alarm Communication System or Mass Notification System El This system does not have an EVACS or MNS system. 13.2.1 Primary Power Input voltage of EVACS or MNS panel: EVACS or MNS panel amps: Overcurrent protection: Type: Amps: Location(of primary supply panel board): Disconnecting means location: 13.2.2 Engine-Driven Generator 12 This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.2.3 Uninterruptible Power System 12 This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode(hours): In alarm mode(minutes): 13.2.4 Batteries Location: Type: Nominal voltage: Amp/hour rating: Calculated capacity of batteries to drive the system: In standby mode(hours): In alarm mode(minutes): ❑ Batteries are marked with date of manufacture ❑Battery calculations are attached ©2009 National Fire Protection Association NFPA 72(p.9 of 12) FIGURE 10.18.2.1.1 Continued Coijyr:ex. 11t T E C.H91%L S C/ E S 2010 Edition 0410 Making a Daily Difference 72-50 NATIONAL.FIRE ALARM AND SIGNALING CODE 13. SYSTEM POWER (continued) 13.3 Notification Appliance Power Extender Panels IN This system does not have power extender panels. 13.3.1 Primary Power Input voltage of power extender panel(s): Power extender panel amps: Overcurrent protection: Type: Amps: Location(of primary supply panel board): Disconnecting means location: 13.3.2 Engine-Driven Generator Q This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.3.3 Uninterruptible Power System 1151 This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode(hours): In alarm mode(minutes): 13.3.4 Batteries Location: Type: Nominal voltage: Amp/hour rating: Calculated capacity of batteries to drive the system: In standby mode(hours): In alarm mode(minutes): ❑Batteries are marked with date of manufacture ❑Battery calculations are attached 14. RECORD OF SYSTEM INSTALLATION Fill out after all installation is complete and wiring has been checked for opens,shorts,ground faults,and improper branching,but before conducting operational acceptance tests. This is a: 0 New system ['Modification to an existing system Permit number: The system has been installed in accordance with the following requirements:(Note any or all that apply.) NFPA 72,Edition: 2013 NFPA 70,National Electrical Code,Article 760, Edition: 2014 0 Manufacturer's published instructions Other(specify): System deviations from referenced NFPA standards: Signed: A-- -AI ft.- Printed name: EC) sQAic.HEZ Date: l! 5/v/ey Organization: r`ery Title: �rrr�t Phone: 3t ) 731 ' mte) ©2009 National Fire Protection Association NFPA 72(p.10 of 12) FIGURE 10.18.2.1.1 Continued _ Co ' r - nt' 2010 Edition TECHIOr E S Making a Daily Difference FUNDAMENTALS 72-51 15. RECORD OF SYSTEM OPERATONAL ACCEPTANCE TEST MI New system All operational features and functions of this system were tested by,or in the presence of the signer shown below,on the date shown below,and were found to be operating properly in accordance with the requirements for the following: Modifications to an existing system All newly modified operational features and functions of the system were tested by,or in the presence of the signer shown below,on the date shown below,and were found to be operating properly in accordance with the requirements of the following: Q NFPA 72,Edition: 2013 NFPA 70,National Electrical Code,Article 760,Edition: 2014 Q Manufacturer's published instructions Other(specify): 4 Individual device testing documentation[Inspection and Testing Form(Figure 14.6.2.4)is attached] . Printed name:6 4s / Date: 7/47;s` Organization: C.-0■-i v'e� Title: c i i/ � 1�C Phones rs 21 K gS1L 16. CERTIFICATIONS AND APPROVALS 16.1 System Installation Contractor: This system,as specified herein,has been installed and tested according to all NFPA standards cited herein. Signed:_ .!- -. Printed name: c.n 5MJ C ktF.7 Date//9/92(5 i • Organization: C('6-- Title: LL,GC' Phone: 36'6 5'.3' ,l PAC) 16.2 System Service Contractor: The undersigned has a service contract for this system in effect as of the date shown below. �� Signed: L�" ` > Printed name: ‘s'G/ J`�"'� " Date: / 175S Organization: Convergint Technologies LLC Title: J � Phone: 503-228-8522 16.3 Supervising Station: This system,as specified herein,will be monitored according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: ®2009 National Fire Protection Association NFPA 72(p.11 of 12) FIGURE 10.18.2.1.1 Continued �Co r,��-- nt� TECH '// I d E J 2010 Edition war Making a Daily Difference 72-52 NATIONAL.FIRE ALARM AND SIGNALING CODE 16. CERTIFICATIONS AND APPROVALS (continued) 16.4 Property or Owner Representative: I accept this system as having been installed and tested to its specifications and all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 16.5 Authority Having Jurisdiction: I have witnessed a satisfactory acceptance test of this system and find it to be installed and operating properly in accordance with its approved plans and specifications,with its approved sequence of operations,and with all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: ®2009 National Fire Protection Association NFPA 72(p.12 of 12) FIGURE 10.18.2.1.1 Continued Co llt� 2010 Edition T E C . • IES Making a Daily Difference